Provider Demographics
NPI:1073531141
Name:PETERSON, JESSICA LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 KENTUCKY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-2853
Mailing Address - Country:US
Mailing Address - Phone:785-856-5353
Mailing Address - Fax:785-856-7320
Practice Address - Street 1:901 KENTUCKY ST STE 102
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-2853
Practice Address - Country:US
Practice Address - Phone:785-856-5353
Practice Address - Fax:785-856-7630
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4930111N00000X
NC3329111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS062152OtherBC&BS
KS062152OtherBC&BS